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SAN JOAGUIN PUBLIC HEALTH SERVICES - ENVIRONMENTAL NE. DIVSION <br /> T STORAGE TANK PROGRAM - FEE WORKSHEET <br /> FACILITY SITE NAME FACILITY CONTACT NAME <br /> T / SITE PHONE # with AREA CODE <br /> E FACILITY/ ADORESST. . <br /> A G <br /> CITY .,� STATE ZIP CODE # of TANKS <br /> A /, lyr�D at SITE <br /> P APPLICANT CONTACT NAME <br /> P APPLICANT/BILLING NAME <br /> L1,2RA e,74�IJ636-GG <br /> C MAILING ADDRESS APPLICAN PHONE # WITH AREA CODE <br /> A l -7 5/ SA4TA A� �2�� ZZZ -BZio <br /> N <br /> T CITYST TE ZIP CODE TYPE of APPLICATION <br /> F-t--1e �o G�3�prj (Closure, installation, etc.) <br /> YY TOTAL <br /> 1986 1987 1988 1989 1990 <br /> ANNUAL FACILITY FEE (Prior to January 1, 1991) = 2100.00 xxxx xxxx j o o rco /00 <br /> A <br /> Cxxxx xxxx /u v 117 1OL) <br /> T FACILITY PENALTY FEES ASSESSED (If Applicable) <br /> I <br /> V TANK FEE = 250.00/TANK (Prior to January 1,1991) 2170/TANK (After January 1, 1991) <br /> E <br /> # Tanks = �_ 1986 1987 1988 1989 1990 1991 1992 7993 1994 1995 1996 <br /> F (multiply # by fee for I 17D 2 <br /> A each year applicable) xxxx xxxx 1207 50 yb )7V (90 <br /> C50D 50 17L2 170 170 2 () i�JO; <br /> I TANK PENALTY FEES ASSESSED xxxx xxxx <br /> L <br /> I STATE SURCHARGE = 256.00 each TANK (Due every 5 years) See California H 8 S Code, Section 25287 <br /> T 1991 through 1996 <br /> Y # Tanks x 256.00 1988 through 1990 <br /> (Enter amount and year) Mp 2 u <br /> C PERMANENT CLOSURE (Removal or Authorized Closure-in-Place) TANK I.D. #(a) <br /> L # TANK(s) 2234.00 = Pd 2 <br /> 0 CLOSURE FEE = 578.00/hour (3 hours minimum/TANK) � % <br /> S <br /> U TEMPORARY CLOSURE (Plan Review 8 Inspections) TANK I.D. #(s) <br /> R <br /> E TEMPORARY CLOSURE FEE = 578.00/hour (3 hours minimum/TANK) # TANK(s)_ X 2234.00 = 2 <br /> P INSTALLATION PLAN CHECK (Plan Review 8 Construction Inspections) TANK I.D. #(s) <br /> L <br /> AS <br /> N PLAN CHECK FEE = 278.00/hour (8 hours minim nVFACILITY) = 2624.00 minimum <br /> R REPAIR FEE (Workplan Review 8 Construction Inspections) TANK I.D. #(a) <br /> — <br /> E <br /> P TANK LINING REPAIR FEE = 278.00/hour (3 hours minimum/TANK) # TANK(s) % $234.00 = t <br /> At <br /> I TANK RETROFIT REPAIR FEE = 578.00/hour (3 hours min./FACILITY) = 1234.00 minimum <br /> R2 <br /> PIPING REPAIR FEE = t78.00/hour (3 hours minimum/FACILITY) = 5234.00 minimum <br /> M TRANSFER FEE = 520.00 UNAUTHORIZED RELEASE EVALUATION = 578.00/hr S <br /> 1 <br /> S t <br /> C CONSULTATION FEE = 578.00/hr SAMPLING INSPECTION FEE = 578.00/hr <br /> TOTAL DUE s <br /> FOR OFFICE USE ONLY ...�._._...._.......... ...---,-:::::.—.... __:!-:::-.—:::::••... ....................:_ <br /> ::......._.............._....._....__._._................_........ <br /> __..... .... .. .. ..... ............ !::e:::!: <br /> SWEEPS # COMPUTER # LOC CODE D[ST CODE AMOUNT RECEIVED CHECK #/CASH RECEIVED BY DATE RECEIVED <br /> 2 <br /> .:::::::::r.:,...:�......... .......... <br /> .............................................................................................................. .i............._ ._......... ...........................:...:.. . .. ........ <br /> .................................:...:.................._.._.................... ..........__..._...�:;; ..... ;_::=._i_Lu4.:_�..w3s'.. <br /> :cu:donn —:...:......:::::: =._a— <br /> C <br /> EN 23 032 (REVISED 6-21-93) �`��� Page 11 �� �� / // -j/ <br />